In the first few days of breastfeeding many women will
have sore nipples.
Breastfeeding with a sore or cracked nipple can be very painful.

The most common cause of sore or cracked nipples is poor breastfeeding
technique.
In many cases the baby is sucking only on the nipple.
The mother is not getting good let- down
and the baby is sucking harder in an attempt to get
more milk.
Mothers need to make sure that the baby opens his or her mouth
wide with the tongue down before they put the baby to breast.
This will allow
the baby to grab the areola into his or her mouth.
When the baby sucks on the areola they compress the milk ducts.
This helps cause milk let-down.
At times during the feeding,
if the mother's arms get tired the baby will start to slip off
and end up sucking on the nipple.
Mothers need to be encouraged to use some support underneath the baby
to help hold up the baby so that this does
not happen (
Freed, 1991
).
Mothers with sore, cracked nipples need to have their breastfeeding
techniques evaluated by a skilled professional. This includes
examination of the breasts and nipples, observation of a feeding
and examination of the infants mouth and sucking.

A candida infection (thrush) can cause sore nipples.
If the baby has white plaques in his or her mouth indicative of a yeast
infection,
the mother may have candida on her nipples.
This can cause nipples to become red and very tender and may be
associated with a burning sensation.
When an infant has a yeast infection in their mouth the mother can
prophylactically put Nystatin suspension on her nipples at the end of
the feeding and allow the medication to dry. This does not have to
be washed off prior to the next feeding. If the mother's nipples
are very red and shiny the suspension may not be effective.
A topical antifungal cream or ointment or systemic antifungal drug
may need to be prescribed by a doctor or nurse.

Women who have moderate to severe nipple pain, along with cracks,
fissures, ulcers or exudates on the nipple,
and good technique,
may have a bacterial superinfection (most commonly Staphylococcus aureus).
The infection may contribute to delayed healing
(
Livingstone, 1996
).
A bacterial culture followed by treatment with appropriate
oral antibiotics may be needed (
Livingstone, 1999
).

At times women's sore, cracked nipples are so painful that the baby cannot
nurse on them.
These mothers may need to pump for 24 to 48 hours in order
to allow the nipples to heal and the baby needs to be fed in another manner
(See
Supplementing breastfed infants in a physiologic manner).

If a woman has mild sore or cracked nipples
that are worse on one breast than the other,
the mother should let the baby nurse first on the less sore breast,
and second on the sore breast.
The baby will suckle less vigorously on the second breast and this may allow
the nipple to heal.

Maternal breast milk placed on the nipples is the best treatment.
The use of breast shells between feedings may also help in the
healing (
Brent, 1998
).

Researchers in Australia compared the vacuum generated by the infant's sucking during
breastfeeding in mothers with persistent nipple pain with the vacuum created by the infant
whose mothers had no pain while breastfeeding.
Infants whose mothers complained of pain applied significantly higher vacuum pressure
during sucking and when pausing.
There was no difference in active sucking times between the 2 groups.
However, infants whose mothers had pain during breastfeeding got less milk during
the feeding than the infants whose mothers were pain-free.
Further study in this area is needed to help mothers with persistent pain during
breastfeeding (
McClellan, 2008
).